Evidence-based preoperative evaluation

Effect of screening abdominal ultrasound examination on the decision to pursue advanced diagnostic tests and treatment in dogs with neurologic disease

BACKGROUND

Abdominal ultrasound examinations (AUS) are commonly performed before advanced neurodiagnostics to screen for diseases that might affect diagnostic plans and prognosis.

OBJECTIVES

Describe the type and frequency of abnormalities found by AUS in dogs presenting with a neurological condition, identify risk factors associated with abnormalities, and evaluate treatment decisions based on findings.

ANIMALS

Seven hundred and fifty-nine hospitalized dogs.

METHODS

Retrospective study. Medical records of dogs presented from 2007 to 2009 for neurologic disease were searched for signalment, neuroanatomic localization, and AUS findings. Whether dogs had advanced neurodiagnostics and treatment was analyzed.

RESULTS

Fifty-eight percent of dogs had abnormal findings on AUS. Probability of abnormalities increased with age (P < 0.001). Nondachshund breeds had higher probability of abnormal AUS than dachshunds (odds ratio [OR] = 1.87). Eleven percent of dogs did not have advanced neurodiagnostics and in 1.3%, this was because of abnormal AUS. Dogs with ultrasonographic abnormalities were less likely than dogs without to have advanced neurodiagnostics (OR = 0.3 [95% confidence interval [CI]: 0.17, 0.52]), however, the probability of performing advanced diagnostics was high regardless of normal (OR = 0.95 [95% CI: 0.92, 0.97]) or abnormal (OR = 0.85 [95% CI: 0.81, 0.88]) AUS. Treatment was more often pursued in small dogs and less often in dogs with brain disease.

CONCLUSIONS AND CLINICAL IMPORTANCE

Findings from screening AUS had a small negative effect on the likelihood of pursuing advanced neurodiagnostics. Although it should be included in the extracranial diagnostic workup in dogs with significant history or physical examination abnormalities, AUS is considered a low-yield diagnostic test in young dogs and dachshunds.

Implementation of an integrated preoperative care pathway and regional electronic clinical portal for preoperative assessment

BACKGROUND

Effective surgical pre-assessment will depend upon the collection of relevant medical information, good data management and communication between the members of the preoperative multi-disciplinary team. NHS Greater Glasgow and Clyde has implemented an electronic preoperative integrated care pathway (eForm) allowing all hospitals to access a comprehensive patient medical history via a clinical portal on the health-board intranet.

METHODS

We conducted six face-to-face semi-structured interviews and participated in one focus group and two workshops with key stakeholders involved in the Planned Care Improvement (PCIP) and Electronic Patient Record programmes. We used qualitative methods and Normalisation Process Theory in order to identify the key factors which led to the successful deployment of the preoperative eForm in the health-board.

RESULTS

In January 2013, more than 90,000 patient preoperative assessments had been completed via the electronic portal. Two complementary strategic efforts were instrumental in the successful deployment of the preoperative eForm. At the local health-board level: the PCIP led to the rationalisation of surgical pre-assessment clinics and the standardisation of preoperative processes. At the national level: the eHealth programme selected portal technology as an iterative strategic technology solution towards a virtual electronic patient record. Our study has highlighted clear synergies between these two standardisation efforts.

CONCLUSION

The adoption of the eForm into routine preoperative work practices can be attributed to: (i) a policy context - including performance targets - promoting the rationalisation of surgical pre-assessment pathways, (ii) financial and organisational resources to support service redesign and the use of information technology for operationalising the standardisation of preoperative processes, (iii) a sustained engagement with stakeholders throughout the iterative phases of the preoperative clinics redesign, guidelines standardisation and the eForm development, (iv) the use of a pragmatic and domain-agnostic technology solution and finally: (v) a consensual and contextualised implementation.

A study of clinical and information management processes in the surgical pre-assessment clinic

Background

Establishing day-case surgery as the preferred hospital admission route for all eligible patients requires adequate preoperative assessment of patients in order to quickly distinguish those who will require minimum assessment and are suitable for day-case admission from those who will require more extensive management and will need to be admitted as inpatients.

Methods

As part of a study to elucidate clinical and information management processes within the patient surgical pathway in NHS Scotland, we conducted a total of 10 in-depth semi-structured interviews during 4 visits to the Dumfries & Galloway Royal Infirmary surgical pre-assessment clinic. We modelled clinical processes using process-mapping techniques and analysed interview data using qualitative methods. We used Normalisation Process Theory as a conceptual framework to interpret the factors which were identified as facilitating or hindering information elucidation tasks and communication within the multi-disciplinary team.

Results

The pre-assessment clinic of Dumfries & Galloway Royal Infirmary was opened in 2008 in response to clinical and workflow issues which had been identified with former patient management practices in the surgical pathway. The preoperative clinic now operates under well established processes and protocols. The use of a computerised system for managing preoperative documentation substantially transformed clinical practices and facilitates communication and information-sharing among the multi-disciplinary team.

Conclusion

Successful deployment and normalisation of innovative clinical and information management processes was possible because both local and national strategic priorities were synergistic and the system was developed collaboratively by the POA staff and the health-board IT team, resulting in a highly contextualised operationalisation of clinical and information management processes. Further concerted efforts from a range of stakeholders are required to fully integrate preoperative assessment within the health-board surgical care pathway. A substantial – yet unfulfilled – potential benefit in embedding information technology in routine use within the preoperative clinic would be to improve the reporting of surgical outcomes.

An Insight Into the Preoperative Experiences of Ghanaian General Surgical Patients

The unknown outcome of surgery has always been a source of anxiety for patients and their relatives. However, the experiences of Ghanaian surgical patients have not been adequately explored. This study sought to have an in-depth exploration of the preoperative experiences of Ghanaian general surgical patients to inform effective preoperative care. The study employed an ethnographic design and was conducted at two hospitals in Accra. Thirteen general surgical patients were purposively recruited and interviewed. Data analysis occurred concurrently and themes that emerged included reaction to impending surgery with subthemes of inappropriate disclosure, fear of death, readiness for surgery, and effect of waiting in the theatre. Also, the theme information gap had subthemes of preoperative care, expectations at the theatre, and undue delays. The study emphasized the need for health professionals to provide effective education to the public and patients, on surgery and its effects, to curb negative perceptions about surgery.

Receptiveness and humanization from the perspective of anesthesiologists

BACKGROUND AND OBJECTIVES

Receptiveness is a tool that brings contributions for health care humanization, especially with regard to its practice in the field of Anesthesiology. The aim was to investigate through the report of anesthesiologists the understanding of the receptiveness phenomenon among these professionals.

METHODS

This is a descriptive qualitative research held at the Hospital Universitário Lauro Wanderley (HULW), in the city of João Pessoa, PB. The sample consisted of 16 attending anesthesiologists, 25% female doctors and 75% male doctors. Data were collected through interviews guided by two semi-structured questions from September to October 2010. Data analysis was performed using the technique of Collective Subject Discourse (CSD).

RESULTS

The anesthesiologists' answer to the following question was considered as this study's result: "What do you think about the practice of receptiveness as a strategy to humanize the doctor-patient relationship?" The doctors' CSD presented two central ideas: 1) a holistic approach to the patient; 2) a strategy that improves the doctor-patient relationship. When asked about the strategies adopted by them to humanize the relationship with the patient at the time of reception, their reports were organized based on three central ideas: 1) observation of patients' rights; 2) therapeutic communication; 3) preanesthetic visit. It was found that the physicians involved in the research recognized the value of receptiveness as a strategy to humanize the doctor-patient relationship.

CONCLUSIONS

The receptivity to the patient in the course of anesthesia is very important because it allows the professional to perform a qualified hearing of the patient's history, together with the humanized care process, which enables the improvement of the interaction between doctor and patient.